• ENDORSED BY THE AMERICAN LAND TITLE ASSOCIATION

  • NOTICE:

    A policy may be issued by your risk retention group. Your risk retention group may not be subject to all of the insurance laws and regulations of your state. State guaranty funds are not available for your risk retention group. The insurance coverage for which you are applying is written on a CLAIMS MADE AND REPORTED policy. Therefore, only claims which are first made against the Insured and reported during the policy period are covered, subject to policy terms, exclusions, and conditions including the notice of claim conditions of the policy. "Claim" means a demand for money or services, alleging a wrongful act by the Insured, including the service of suit or institution of arbitration proceedings.

  • INSTRUCTIONS:

    Please answer all questions completely. This form must be completed, signed, and currently dated by an owner, member, principal, or officer of the firm applying for coverage. ACTIVE MEMBERSHIP IN THE AMERICAN LAND TITLE ASSOCIATION (ALTA) IS REQUIRED TO RENEW THIS COVERAGE.
  • 2. Additional Offices/Locations*
  • 3. List ALL states where Applicant operates:*
  • 4. Have there been any changes in the firm's organization, ownership, or operations since last year?*
  • 5. Applicant's business activities:*

  • 7.  OWNERS AND STAFF (count each person only once):

  • d. Are independent contractors hired to search titles or to perform closings or other services?
  • e. If YES to 7d, do independent contractors maintain their own E&O insurance?*
  • 8. GROSS REVENUE: show all revenue, fees and commissions before deduction of expenses. *
    Rows
  • 9. Is the Applicant controlled by or owned by or associated with, or does the Applicant control or own, any other firm or business?*
  • 10. Is the Applicant (including any owner, partner, member, director, officer or employee), any subsidiary, parent or other related or affiliated organization engaged in: title underwriting as an insurer; real estate brokerage or sales; real estate development or construction; real estate lending; the formation, management or organization of group investments/syndications (including limited partnerships, general partnerships, real estate investment trusts or corporations); the practice of law or any business enterprise or professional practice OTHER THAN title agency, abstracting/searching or escrow/closing? If YES, please explain in the space below.*
  • 11. Limits of Liability (each claim/annual aggregate) requested*
  • Deductible (each claim) requested:*
  • 12. After inquiry of all persons identified in response to question 7.a., during the past year, has any claim been made or are there any circumstances which may result in a claim that have NOT BEEN REPORTED to TIAC?*
  • 13. During the past year, has the Applicant or any person identified in response to questions 7.a. had an agency agreement terminated, a license revoked or suspended, or been formally reprimanded or subject to disciplinary action?*

  • I/We hereby warrant, after inquiry of all persons identified in response to question 4, that the above statements and particulars are true and that I/we have not suppressed or misstated facts. I/we agree that this Application, including any attachments, shall be deemed to be material to the risk assumed by TIAC; shall be the basis of the contract with TIAC; and that any policy issued may be affected by any suppressed or misstatement. It is understood and agreed that this Application forms a part of any policy issued by TIAC to the Applicant and shall be deemed to be attached to and form a part of the policy. It is understood and agreed that completion of this Application does not bind TIAC to issue not the Application to purchase any policy.

    If thre is any significant change in the operations of the Applicant, or if any information supplied in the Application or any attachement to this Application changes between the date of the Application and the policy inception date, which would render this Application or any attachment to this Application inaccurate or incomplete, the Applicant agrees to provide immediate notice in writing to TIAC of any such change.

    Any material misrepresentation or concealment in apply for this policy or in pursuing a claim under this policy shall be deemed ground for denial of coverage and/or cancellation or recission of this policy.

  • PRIVACY BREACH AND CLIENT FUNDS PROTECTION COVERAGE SUPPLEMENTAL APPLICATION

    Applicant's Instructions - Please Read Carefully

  • (a) This form is to be completed by all Applicants.

    (b) Answer all questions and please neatly print or type all answers.

    (c) An owner, member, principal, or officer of the Applicant firm must sign this page in addition to the last page of the TIAC Professional Liability (E&O) Application.

  • 2. Does the Applicant have written computer and information system policies and procedures in place?
  • Do you require all employees to take training and follow procedures?
  • 4. Does the Applicant have anti-virus, anti-spyware and firewall software installed and enabled on all desktops, laptops, portable electronic devices and servers and is it updated on a regular basis?
  • 5. Does the Applicant have and enforce policies concerning the encryption of internal and external communications and records?
  • 6. Does the Applicant wire funds?
  • If YES, are staff responsible for wire transfers provided with anti-fraud training including the detection of social engineering, phishing, spear phishing or other confidence tricks?
  • 7. Do you utilize dual authorization protocols on all external payments whereby a 2nd individual has to authorize a payment or wire/funds transfer?
  • 8. Does the Applicant ever accept email instructions concerning distribution of funds?
  • 9. Does the Applicant verify with the issuing financial institution the authenticity of cashier’s checks purportedly issued by that institution?
  • 10. After inquiry of all owners, partners, members and employees, is the Applicant aware of any breach, hacking, release of data, violation of any breach regulation or law, or any circumstances which may give rise to a claim under the insurance being applied for?
  • 11. Has any Privacy Breach or Loss of Funds claim, complaint, demand or regulatory proceeding ever been made or initiated against the Applicant?

  • The information submitted herein becomes a part of the Professional Liability (E&O) Insurance Application and is subject to the same representations and conditions.

  • Date
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    2 digit month, 2 digit day, 4 digit year
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